Following a three week inquest at Warwickshire Justice Centre, a jury has returned a narrative conclusion finding that multiple police errors and omissions contributed to the death of Luisa Mendes.

Luisa was a very vulnerable woman: she had a recorded history of being the victim of domestic violence and abuse. She had alcohol dependency, was unemployed, and homeless. In the lead up to her death, she had had repeated interactions with the police who had undertaken numerous inconsistent risk assessments. She had presented on a number of occasions at hospital with varying injuries. She was in and out of prison for petty criminal offending. The probation service suspected that she was being sexually exploited.

Luisa resided on a casual basis with CT at his home. CT was also an alcoholic and has suspected Korsakoff Syndrome (alcohol induced dementia). Another individual with alcohol dependency and homelessness issues, NW, also stayed at the address. Both CT and NW had convictions for violent offending.

On 24 October 2012, Luisa rang 999 alleging that she had been and was being beaten or touched by NW. On two occasions during the call, the phone was taken from Luisa and the line was cut. The 999 call handler recorded on the call log that Luisa was alleging assault but nonetheless categorised the call as one of “rowdy/nuisance” rather that “violence”. The call was graded a “priority”, thereby requiring a police response as soon as possible or within one hour. The intelligence checks which were uploaded to the call log gave a partial picture of Luisa as being “drunk” and “violent”. Her vulnerable history was not documented at all.

The 999 call was transferred to police staff responsible for dispatching police resources, known as “controllers”. Three controllers failed to pick up on the repeated allegations of assault and the incorrect call categorisation. They all accepted that had they properly interrogated the call log, they would have recategorised the call to one of “violence”. The controllers’ assessment of the call log was that Luisa was the troublemaker and that it was a verbal altercation.

The three controllers failed to dispatch police resources as soon as possible or within the hour. This is despite police resources being available and the incident log turning a different colour once the permitted deployment period had expired. Over 2 ½ hours after the call was transferred to the controllers, two of the controllers decided that the call required a “scheduled response”. The call was subsequently downgraded and the incident was deferred until the next morning. The controllers accepted that they had no power to defer a priority incident without a supervisor’s agreement. The control room Inspector failed to identify that a priority call had exceeded its deployment time. The Inspector’s evidence was to the effect that priority calls with a grading of “rowdy/nuisance” would not be picked up by an inspector or supervisor, although “violent” priority calls would.

On 25 October 2012, Luisa Mendes was found dead at CT’s home, lying on the bathroom floor. The jury found the medical cause of death to be catastrophic bleeding to her abdomen from a rupture to her spleen, which was caused by deliberate third party trauma. Following her death, both CT and NW denied assaulting her. CT subsequently gave an interview in March 2013 admitting that he had repeatedly punched Luisa to the stomach.

During the course of the Inquest proceedings, the Chief Constable and those representing the police staff argued that an Article 2 ECHR inquest was not required. On behalf of Luisa’s brother, it was argued that an Article 2 ECHR compliant inquest was required on the bases that (i) there were arguable systemic breaches of the obligation to put in place effective systems to protect life, and (ii) that the police had failed to respond to a real and immediate risk of violence (and associated threat of injury) in the context of a woman with a background of known domestic violence (following the Court of Appeal’s decision in Michael v Chief Constable of South Wales). Following extensive legal argument, the Coroner eventually ruled in April 2016 that there were arguable breaches of the general duty to put in place effective systems to protect life and ordered that there be an Article 2 ECHR compliant inquest.

On day four of the inquest, Queen’s Counsel representing CT (pro bono) sought to have the inquest adjourned so as to secure funding. The Chief Constable (represented by Queen’s Counsel and junior counsel) and the police staff (represented by experienced junior counsel) supported the application; while Luisa’s family opposed it. The Coroner agreed with the family that the application was inappropriate, late and that the prospect of funding was remote. The Coroner accordingly refused the application.

Following the conclusion of the evidence, and having heard over 20 witnesses, including the Chief Superintendent of Warwickshire Police, those representing the Chief Constable and the police staff argued that a judgemental narrative ought to not be left to the jury. They argued that, owing to the diseased nature of the spleen, coupled with the purported unreliability of the evidence of CT and NW, a jury could not conclude that the rupture to the spleen was caused by third party trauma. Further, the other parties argued that the jury could not conclude that proper police intervention would have made any difference to the outcome.

Agreeing with the Family, the Coroner dismissed those arguments and found that the jury could safely conclude that Luisa was assaulted; that the assault caused the spleen to rupture; and, that proper police intervention may have resulted in a different outcome.

After a day and a half of deliberations, the jury unanimously concluded that there were police errors and omissions in (i) the call categorisation, (ii) the handover procedures for the police controllers, (iii) the deferral of the 999 call, (iv) the police computer systems, and (v) the supervision of the police staff. The jury concluded that these errors or omissions possibly caused or contributed to Luisa’s death.

The Coroner has stated his intention to issue a Prevention of Future Deaths Report, although those representing the Chief Constable continue to seek to limit the ambit of that report.

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